Assisting a Child with Attention Deficit Disorder
We have carefully considered all you have said and wished it would work for us, but our son has ADD. His medication is helping him some, but he still has a hard time controlling himself, especially on weekends when his doctor said it is good for him not to take his pills. Is there any way this approach can help in our situation?
Children with Attention Deficit Disorder present enormous challenges to their parents and teachers, as illustrated in this anecdote:
Nine-year-old Dirk was referred by his pediatrician and brought in by his parents. He had been on medication for years for hyperactivity and distractibility, hallmarks of ADD. Dirk’s behavior problems had escalated both at home and school despite several increases in dosage over the last couple of years and the pediatrician was reluctant to increase it again.
To be sure I wouldn’t miss important details, I took notes as the parents enumerated their many concerns about this boy. Dirk, meanwhile, roamed my office, displaying many of the behaviors his parents were telling me occurred regularly at home and school. He poked through the toys but played with none, pushed and pulled at books on the shelves, crawled behind the desk, fiddled with the curtains, and generally was unfocused and constantly active.
After half an hour, the parents left and I met with Dirk alone. Asked why they had come to see me, he said that he didn’t know. Asked what his parents had told me, again he said he didn’t know, and he continued to squirm and wiggle, occasionally slithering out of the chair that I’d asked him to sit in while we talked. After a time, I told him I could see it was difficult for him to remember what we had talked about and that I was going to help. I drew a star on a piece of paper with a red marker and told him that for each one of his parents’ concerns that he could tell me, I would draw him a star.
Dirk said that he hadn’t been listening and thus didn’t know. With some urging, he finally mumbled vaguely about something his parents had mentioned, and I quickly drew a star on the paper as he watched. Again he insisted that he couldn’t tell me anything else, but with more urging, he came up with another concern, this time in richer detail. As I drew his second star, I commented that we had just gotten started and already he had thought of two things. By then the boy was sitting in his chair and seemed interested although still asserting he couldn’t think of anything. But more quickly, he added another of his parents’ concerns and before I had drawn his third star, he was telling me of another. I won’t continue with each step, but by the time we were done, he had mentioned all but one or two of the rather long list of concerns I had written in my notes, and he had nearly a dozen stars on his paper. More impressive still, he sat in his chair looking stunned – but excited – as he considered his stars and exclaimed, “Wow! I can’t believe I remembered all those things.”
As the parents returned to the office, Dirk jumped up and thrust his sheet of stars at them. He told them excitedly that he had been able to tell me almost everything they had said about his problems, adding at the end, “And I didn’t think I was even listening.” Initially the parents reacted to Dirk’s excited outburst as typical for Dirk. Still, when the boy sat back down in his chair, they did seem to notice. I asked him then to tell them some of the things he had told me, and he rattled off several of the items in a remarkably organized and clear fashion, running his finger down the row of stars as if ticking them off as he spoke. His parents listened in apparent disbelief and then turned to me for comment. I further described what happened, noting that the boy had displayed internal resources that seemed at odds with his history.
To make a long story manageable, we spent another half hour or so together, building on the experience in the office by designing a simple reward program. Our intention was to support this boy’s success in focusing his attention and maintaining appropriate control over his behavior in key situations at home with a simple addition for school. The parents, themselves, clearly as stunned as they were hopeful, asked about the medication. I urged them to wait until we could determine how their son managed with the new behavior checklist, and then we could communicate with the pediatrician about what might be best to do.
A couple of weeks later, the family returned with the charts from their program, all three regaling me with stories about how well Dirk had been doing, all clearly reflected in the data from their charts.
As this second meeting ended, I suggested that the parents talk to the pediatrician, hopeful that he would agree there was no reason to raise the dosage. I was startled to learn that the parents had chosen to discontinue the medication on their own only a couple of days after our initial visit, not something I would have recommend. Still, in this case the boy had been medication-free for ten days without complications and the successes they described actually occurred without benefit of medication.
It seemed clear to me that the most important change in this situation came about because of this boy’s markedly altered view of himself. He went from seeing himself as incapable of noticing anything or of containing his own squirminess to announcing that he had, and could, tell me most of what his parents had said, a change that carried over long after they left my office.
So what is the point of this anecdote? While I share concerns that medication may be overused in some children, clearly there are children for whom medication provides essential support for their capacity to deal constructively with a world that otherwise is overwhelming and discouraging. Thus, it is not my intention to suggest that all children should be taken off medication and put on a home program and surely not without consulting the child’s doctor.
Nor do I have any illusions that our simple program overcame this boy’s attention and behavior control problems. I think it is likely that for some unknown reason his nervous system had matured beyond his need for medication. But because he had already come to see himself as a “hyper” kid who couldn’t be expected to control himself, he lived accordingly. Once he discovered this was no longer true, he was able to refocus his internal resources and function much more effectively.
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A characteristic of the normal child is he doesn’t act that way very often.
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But what about the many children with this condition who may or may not benefit from medication and who are still struggling to fit in at home and school? Every child must learn to function adequately in the world with whatever demands and expectations that entails. Because children with attention and control struggles typically have a more difficult time meeting expectations, they are in special need of help in focusing their behavior.
The approach described in this book is especially well suited to provide that focus. By carefully defining realistically reachable expectations put in positive terms, by providing meaningful incentives for meeting those expectations, and by consistently managing the connections among the elements of a home program, parents of such children can support continuing maturation toward effective behavior control and – ultimately – self-responsibility.
My answer to you, then, is that the approach presented here might be very well suited to your needs. Your challenge will be carefully to design a program to meet your son where he is, to support his moves toward better self control, and to nurture his awareness of his progress as it occurs so that he fully appreciates his own capacities. The only aspect of your challenge that might seem specific to ADD is that extra care may be required to assure your target behaviors are in small enough steps for your child to succeed. Thus, an appropriate item for a child without ADD might be:
Conrad, you are successful when you complete your math problems during study period.
A child with ADD, on the other hand, may require several less demanding items to cover the same basic task:
Albert, you are successful when you stay at your desk for ten minutes,
Albert, you are successful when you write your assignment on your daily log, and
Albert, you are successful when you complete five math problems during study period.
As you can see, I have emphasized for you the importance of special care in defining target behaviors – specifically to assure that each item you include is truly realistically reachable for your son in the light of his extra struggle to stay focused. Chosen carefully, the successes for those items, however small at first, can be the foundation for continuing growth for you both.